Inquest into the death of Kelvin Forrest

53y · Male·multiple injuries sustained in a fall from the first floor

Kelvin Forrest, a 53-year-old man with Down syndrome and dementia, died from multiple injuries sustained in a fall from the first floor of Byron Central Hospital on 28 July 2018. He had been admitted as a medical patient awaiting NDIS funding approval for supported independent living. Despite documented frequent wandering behaviour, including an incident where he was found on the road outside the hospital, supervision was inadequate. A veranda door was left unlocked to accommodate another patient's behavioural needs, allowing Kelvin to access the roof where he fell. The coroner found the death preventable, noting that consistent 24-hour specialised supervision from admission would likely have saved his life. Key failings included inadequate risk assessment of wandering behaviour, failure to escalate concerns to senior medical staff, incomplete handover of risk information between shifts, delays in NDIS funding approval, and poor coordination between hospital discharge planning and disability support services.